The effect of indapamide versus hydrochlorothiazide on ventricular and arterial function in patients with hypertension and diabetes: results of a randomized trial.

OBJECTIVE: The objective of this study is to compare the effects of 2 types of diuretics, indapamide and hydrochlorothiazide, added to an angiotensin-converting enzyme inhibitor, on ventricular and arterial functions in patients with hypertension and diabetes. METHODS: This is a prospective, randomized, active-controlled, PROBE design study in 56 patients (57 ± 9 years, 52% men) with mild-to-moderate hypertension and type 2 diabetes, with normal ejection fraction, randomized to either indapamide (1.5 mg Slow Release (SR)/day) or hydrochlorothiazide (25 mg/d), added to quinapril (10-40 mg/d). All patients had conventional, tissue Doppler and speckle tracking echocardiography and assessment of endothelial and arterial functions and biomarkers, at baseline and after 6 months. RESULTS: Baseline characteristics were similar between groups; systolic and diastolic blood pressures decreased similarly, by 15% and 9% on indapamide and by 17% and 10% on hydrochlorothiazide (P < .05). Mean longitudinal systolic velocity and longitudinal strain increased by 7% and 14% on indapamide (from 5.6 ± 1.8 to 6.0 ± 1.1 cm/s and from 16.2% ± 1.8% to 18.5% ± 1.1%, both P < .05), but did not change on hydrochlorothiazide (P < .05 for intergroup differences), whereas ejection fraction and radial systolic function did not change. Similarly, mean longitudinal early diastolic velocity increased by 31% on indapamide (P < .05), but did not change on hydrochlorothiazide (P < .05 for intergroup differences). These changes were associated with improved endothelial and arterial functions on indapamide, but not on hydrochlorothiazide. CONCLUSION: Indapamide was found to improve measures of endothelial and arterial functions and to increase longitudinal left ventricular function compared with hydrochlorothiazide in patients with hypertension and diabetes, after 6 months of treatment. This study suggests that indapamide, a thiazide-like diuretic, has important vascular effects that can improve ventriculoarterial coupling.

Minimum Left Atrial Volume Evaluated by 3D Echocardiography Predicts Atrial Fibrillation Recurrences After a First Radiofrequency Catheter Ablation for Paroxysmal Episodes.

Background: Concomitant atrial fibrillation (AF) in non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients complicates the decision-making process regarding short- and long-term antithrombotic strategies. Patient profiles and usage rates of different antithrombotic combinations in this patient subgroup in Romania are poorly described. Study aim: To evaluate the relationship between LA dimensions and AF recurrences (AFR) using echocardiography. Methods: We enrolled 40 patients (56 ± 10 years; 73% males) who underwent a first RFCA for paroxysmal AF. Bi- (2DE) and three-dimensional (3DE) echocardiography was performed prior to RFCA and at 12-months follow-up. Rhythm control was monitored for up to two years after the intervention by periodic ECG Holter monitoring. Results: Atrial fibrillation recurrences were recorded in 21 patients (52%) in the first year after RCFA. The only predictor of outcome from pre-ablation LA parameters was 3DE minimum LAVi (p = 0.042), that explained 21.4% of AF recurrences in the first year, with a cut-off value of 21.29 mL/m². The mean 3DE min LAVi was 24.29 ± 8.01 mL/ m² and patients without AFR in the first year had a lower LAVi than those with AFR (20.92 ± 6.19 mL/m² vs. 27.25 ± 8.43 mL/m², p=0.028). One year after RFCA, a decrease in medio-lateral, superior-inferior diameters and volumes were recorded in AF free patients. Eleven patients (27%) had AF recurrences after the first year and LAV 12-months after RFCA were found to be predictors of long-term outcome, with minimum LAVi as the strongest predictor of recurrences (p=0.014), explaining 36% of episodes, with a cut-off over 22.49 mL/m². Conclusion:Radiofrequency ablation controls LA remodeling in patients with clinical success in terms of AF freedom. Left atrium 3DE volumetry is accurate in predicting RFCA outcome.

New Echocardiographic Protocol for the Assessment of Experimental Myocardial Infarction in Rats.

BACKGROUND: The rat infarct model was used extensively to study the pathophysiology of myocardial infarction and to evaluate different therapies. Transthoracic echocardiography is used in rats in order to assess cardiac anatomy and function, being a safe and reliable non-invasive technique. However, studies combining conventional with new echo techniques, such as tissue Doppler imaging (TDI) and speckletracking echocardiography (STE), are lacking. OBJECTIVES: To validate a protocol using the available conventional and new echocardiographic techniques (TDI and STE) for a comprehensive assessment of cardiac remodelling and function, after myocardial infarction in rats. METHODS: Ten Wistar (W) and five Sprague Dawley (SD) male rats (aged 21±2 weeks, mean weight 355±43 g) were evaluated by echocardiography, before and 24 hours post-ligation of the left coronary artery, with previous anaesthesia. Left ventricular (LV) structure was assessed by end-diastolic and endsystolic anterior wall thickness and LV diameters (from the SAX view), while LV function by fractional shortening (FS) and ejection fraction (EF) (by area-length formula), septal mitral annular plane systolic excursion (MAPSE), cardiac output (CO), myocardial performance index (MPI), septal mitral annular systolic velocity (S', by TDI), and global circumferential and radial systolic strain (GCS, GRS) and strain rate (GCSr, GRSr) by STE, from the SAX view at the level of papillary muscles. RESULTS: Feasibility of measuring the above mentioned parameters was 100%. Twenty-four hours after myocardial infarction, rats had lower heart rate (373±44 vs. 351±32 bpm, p<0.05) and thinner LV anterior wall, while LV diameters and volumes were significantly higher. FS (54±7 vs. 33±9%), EF (72±9vs. 47±10%), septal MAPSE (2.02±0.17 vs. 1.44±0.22 mm), CO (76±15 vs. 48±12 ml/min), MPI (0.33±0.11 vs. 0.50±0.14), S' (5.58±1.20 vs. 3.84±1.06 cm/s), and LV strain and strain rate (GCS: -23.52±2.44 vs. -13.33±1.51% and GRS: 50.45±13.11 vs. 17.27±5.2%, GCSr: -8.42±0.85 vs. -4.68±0.53; and GRSr: 11.93±2.39 vs. 4.89±1.18 1/s) were significantly lower, all p<0.01. CONCLUSIONS: Our echocardiographic protocol of experimental myocardial infarction in rats is feasible. The impact of myocardial infarction in rats could be more extensively assessed using a comprehensive echocardiographic protocol of conventional and specific myocardial parameters, measured by TDI and STE, in order to quantify better the LV structure and function. Therefore, we suggest that this protocol may be used in order to assess the effect of different regenerative therapies in experimental myocardial infarction in rats.

Worsening of Heart Failure after Abdominal Surgery - Can we predict it?

BACKGROUND: The cardiopulmonary test has demonstrated its role in predicting long term prognostic of patients with heart failure, but only few data are available regarding its utility on short term period. METHODS: During 2011-2013, the study enrolled 55 patients over 18 years, with different cardiovascular, metabolic and/or pulmonary pathologies, and 10 control patients matched for age, sex and surgical intervention type, without an associated pathological history who underwent elective abdominal surgery with general anesthesia. RESULTS: The most important predictors of the heart failure worsening after abdominal surgery were peak VO2 as percent of predicted VO2 lower than 59.42±12.52, ventilator equivalent for CO2 at anaerobic threshold over 39.53±5.27 and VD/VT ratio at anaerobic threshold over 0.33±0.06. Lean VO2 lower than 9.58±2.47 also correlated with the above mentioned complication. The ventilator equivalent for CO2, above 39.53±5.27 at anaerobic threshold, respectively 40.67±6.73 at peak exercise, correlates with short term worsening of heart failure after general anesthesia for abdominal surgery. CONCLUSION: The CPX test has a certain value in predicting short term worsening of heart failure after general anesthesia for elective abdominal surgery in patients known with cardiovascular, pulmonary and/or metabolic disorders.

The impact of blood pressure variability on subclinical ventricular, renal and vascular dysfunction, in patients with hypertension and diabetes.

BACKGROUND: Blood pressure variability (BPV) was proved as a cardiovascular risk factor. One of its mechanisms is related to arterial stiffness and ventriculo-arterial coupling; however its impact on subclinical cardiovascular dysfunction has not been evaluated yet. OBJECTIVES: To assess the relationship between BPV on 24 hours, and subclinical left ventricle (LV), renal, and vascular dysfunction in diabetic and hypertensive patients. MATERIAL AND METHODS: We studied 56 patients (57±9 years, 29 men) with mild-to-moderate hypertension and type 2 diabetes, no cardiovascular disease, normal ejection fraction and normal renal function. 24 hours ambulatory blood pressure monitoring (ABPM) was used to assess BPV, daytime (d) and night time (n), by: 1. mean (M); 2. standard deviation of mean (SD); 3. variance (Vr); 4. coefficient of variation (CV); 5. day/night variation: reverse dippers, non-dippers, dippers and extreme dippers; conventional and 2D speckle tracking echo to assess LV function; myocardial deformation was measured as global longitudinal strain (GLS). Endothelial (flow mediated dilation, FMD) and arterial function (intima media-thickness, IMT; pulse wave velocity, PWV), microalbuminuria were tested. OUTCOMES: Daytime BPV correlates inversely with subclinical myocardial function evaluated through GLS. Daytime systolic BPV correlates positively with IMT (all rho > 0.30, all p < 0.05). Also, there is a significantly inverse correlation between mean BP and GLS. We found a direct correlation between mean BP, but not BPV, and microalbuminuria (all rho > - 0.30 and all p < 0.05). We found no correlation between BPV and FMD, PWV. There were no differences for GLS, microalbuminuria and FMD between dipper groups. CONCLUSIONS: In diabetic patients with mild-to-moderate hypertension, increased daytime blood pressure variability correlates with subclinical left ventricular dysfunction and arterial function (IMT), while microalbuminuria correlates with elevated blood pressure, but not with blood pressure variability.